Healthcare Provider Details

I. General information

NPI: 1063486595
Provider Name (Legal Business Name): BURTON ALLAN BENSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14001 RIDGEDALE DR STE 100
MINNETONKA MN
55305-1781
US

IV. Provider business mailing address

14001 RIDGEDALE DR STE 100
MINNETONKA MN
55305-1781
US

V. Phone/Fax

Practice location:
  • Phone: 952-473-0211
  • Fax: 952-473-7908
Mailing address:
  • Phone: 952-473-0211
  • Fax: 952-473-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29930
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: